Rarely does a single study change the course of gynecological history. But a clinical trial published this year in The New England Journal of Medicine did just that, seeming to close the door on one of the great enigmas of women’s health.
Bacterial vaginosis, or B.V., is the most common vaginal infection worldwide. If you have a vagina, there’s a one-in-three chance you will have B.V. at some point in your life.
For years, doctors have known that the bacteria associated with the condition could also be found on the penis. Yet on paper B.V. was just a vagina problem — it’s right there in the name, vaginosis. For 50 years, gynecology treated it as if it were solely a women’s issue, with ineffective treatments that left women vulnerable to re-infection.
The New England Journal study changed that. The researchers followed 150 heterosexual couples in which the female partner had bacterial vaginosis. They treated the women with first-line antibiotics, and half the men with both oral and topical antibiotics. Within three months, they found, the partner treatment worked so well that they had to disband the study so all participants could be treated.
Their conclusion: B.V. could be transmitted via sex, and should be treated as like a sexually transmitted infection.
For doctors who treat the condition regularly, the study results felt like a vindication. “It’s just so obvious,” said Dr. Sarah Cigna, a gynecologist who runs a sexual health clinic at George Washington University. “It’s not rocket science.”
The study spread like, well, an S.T.I. In October, the American College of Obstetricians & Gynecologists advised its more than 60,000 members to begin offering treatment for male partners of patients with persistent B.V. In November, California became the first state to recommend that all providers treat male partners. And this month, New York City announced that all its sexual health clinics would now treat male partners as well.
“This is going to change practice in a profound way,” said Dr. Ina Park, a sexual health researcher at the University of California, San Francisco, and a medical consultant for the Centers for Disease Control and Prevention’s division of S.T.D. prevention.
An Ever-Shifting Border
Since the journal article came out, some doctors have started calling B.V. a sexually transmitted infection when they talk to patients. Others, like Dr. Cigna, are more hesitant, in part because they believe the stigma of an S.T.I. still outweighs the stigma of a vagina problem.
The fact that there is debate at all shows that the definition of an S.T.I. is still in flux, said Dr. Jeffrey Klausner, a professor of medicine and public health at the University of California, Los Angeles.
Biologically, most conditions classified as S.T.I.s defy binary definitions. The word “sexually,” for starters, rarely tells the full story. “When people hear ‘S.T.I.,’ they think penis went into vagina and caused infection,” Dr. Cigna said, when in reality sex encompasses far more than penile penetration.
HPV, which became known as an S.T.I. in the 1980s, can be passed on by close touching or kissing; the virus is often found lingering under teenage boys’ fingernails. H.I.V. and herpes can be transferred through shared needles, organ transplants or blood transfusions, or through the placenta during pregnancy — no sexual contact required.
The reverse is also true. Viruses not typically considered sexual, like Ebola or Zika, can live in semen for days. Mononucleosis, also known as “the kissing disease,” can be transferred via sex. So-called oral herpes is often found on the genitals.
In 2022, Dr. Klausner had a hand in the making of a ‘new’ S.T.I.: Mpox, which he argued should be reclassified after a global outbreak linked to men who have sex with men.
The decision was as strategic as it was scientific. The goal was “getting thought leaders to agree that yes, this was predominantly a sexually transmitted infection and should be approached with our tried-and-true methods for controlling S.T.I.s,” he said.
In theory, labeling bacterial vaginosis as an S.T.I. could also lead to more robust public health efforts at education and control, Dr. Klausner said. But relabeling comes with cons as well as pros. With Mpox, medical authorities had to weigh the utility of the S.T.I. designation against the likelihood that it would fan the flames of homophobia and make people less likely to seek care or to notify partners.
If the category of S.T.I.s were a conflict-ridden country, B.V. would be a town on one of its ever-shifting borders. The condition changes hands depending on the era and the situation, revealing that those borders were largely artificial to begin with — and making some doctors question the limits of this construct.
S.T.I. or Not?
Bacterial vaginosis challenges the conventional definition of an S.T.I. in several ways. First, it isn’t caused by one infecting agent, like chlamydia or gonorrhea. Instead, it is more of an ecosystem shift in the vaginal microbiome, the teeming community of bacteria that patrol the genitals.
“It’s a gemisch of stuff,” said Dr. Caroline Mitchell, a gynecologist and director of the vulvovaginal disorders program at Massachusetts General Hospital. “It’s not just one thing, it’s a pattern.”
Second, B.V. can be transmitted through sex, but researchers disagree about whether it always begins that way. Even Dr. Catriona Bradshaw, the lead author of the study and a clinician at the Melbourne sexual health Center at Monash University, is circumspect: “It’s better to think of B.V. as being sexually transmissible,” she said.
They know that once you’ve had it, any change in the pH of the vagina can allow B.V. bacteria to proliferate, said Dr. Lonna Gordon, an adolescent medicine specialist at Nemours Children’s Health in Florida.
That change could be set off by douching, condoms, smoking, lubricants, toys, an IUD, hormones, semen or a menstrual period. “You just need to have something that disrupts that environment, which could be a bubble bath, wearing a swimsuit too long, yoga pants,” Dr. Gordon said. Yes, yoga pants.
By bringing all of these exceptions together, B.V. is forcing researchers to examine a long-overdue question: Is the term S.T.I. still clinically useful?
“The whole conversation maybe needs to change,” said Dr. Supriya Mehta, an epidemiologist at the University of Illinois, Chicago, who studies S.T.I.s and the genital microbiome. “Like, who cares about an S.T.I.? It’s just a cold that happens to be in your vagina or penis, right?”
Regardless of what doctors call B.V., the failure to recognize that it spreads sexually has meant that doctors have been deprived of a critical method for eradicating an incredibly widespread condition, with profound consequences for patients.
“Everything for the vagina is behind, always,” Dr. Cigna said.
Not Rocket Science
For years, Dr. Cigna fought B.V. with one hand tied behind her back. Every doctor who treated the condition regularly could see that patients were being reinfected, either by a new partner or the same partner.
But without clinical guidelines, she could treat a patient who had B.V. only with antibiotics or, as a last resort, a microbiome-decimating medication known as boric acid. These methods seldom worked over the long term. For more than half of patients, bacterial vaginosis comes back within six months of treatment.
This is a major problem. Besides causing irritation, discharge and an unpleasant smell, the condition can worsen pregnancy outcomes and make it easier to get H.I.V., herpes or another S.T.I., a burden that falls disproportionately on Black women and other women of color.
The “cure” often compounds the problem. Many patients are prescribed numerous rounds of antibiotics, which can lead to antibiotic resistance.
“What we currently do for B.V. is so bad that people are jumping on this bandwagon,” said Dr. Mitchell at Mass General. “We’re all desperate for something more.”
For some patients, thinking of B.V. as an S.T.I. is liberating. One of Dr. Cigna’s patients, a 29-year-old transgender man who had struggled with chronic B.V. for nearly a decade, brought the study in to his appointment in April after coming across it on social media.
The man, who asked not to be identified to avoid discrimination by future employers, said he had always chafed at his doctors’ insistence that B.V. was a vagina problem, “considering that I pretty exclusively got it from sex,” he said. “It just seemed a little bit, like, blamey, to me.”
But if B.V. was sexually transmitted, it meant his partner could be part of the solution. He and Dr. Cigna entered the appointment with the same idea: Maybe partner treatment could be an answer.
Thanks to the study, Dr. Cigna was able to recommend that he take boric acid — he had already undergone more than six rounds of antibiotics — while his partner was also treated.
Not a ‘You’ Problem, a ‘We’ Problem
Like most advancements in modern gynecology, the discovery of bacterial vaginosis can be traced back to a male doctor experimenting on his patients without consent. The doctor, Dr. Herman Gardner, suspected that B.V. must be a result of some pathogen being transferred back and forth.
In 1955, Dr. Gardner performed an appalling experiment to find out. He transferred vaginal fluid from 15 women who had B.V. into the vaginas of women who did not have the condition, and he allowed the newly infected women to pass B.V. on to their unsuspecting husbands.
Upon culturing bacteria from some of the husbands, Dr. Gardner declared B.V. to be “the most prevalent and one of the most contagious” of all S.T.I.s. For his efforts, Dr. Gardner’s name was forever enshrined in the species of bacteria most associated with B.V.: Gardnerella vaginalis.
In the decades since, a handful of studies have tried to replicate the findings using more ethical practices. All failed, leaving doctors with the impression that B.V. was not actually a sexually transmitted infection.
There were hints that those studies were flawed. Researchers knew that recurrence was much higher in women who had a regular sexual partner or who did not use condoms. They also knew that the vaginal microbiomes of women partnered with women resembled each other under the microscope; if one had B.V., the other probably did, too.
“So why wouldn’t it be transmitted between penises and vaginas?” Dr. Bradshaw asked.
She attributed the failure of past studies to paltry funding, shoddy research design and the challenge of getting men to commit to studies that do not benefit them personally.
In May, Dr. Bradshaw was listed as one of Time magazine’s 100 most influential people in health for “reframing a ‘women’s issue’” as a public health issue. No longer was B.V. a shameful, secret “vagina problem.” Now it was a problem shared between members of a sexual partnership. Not a “you” problem, but a “we” problem.
Doctors do not have to call B.V. an S.T.I. in order for patients to benefit. They could describe it using a more neutral-sounding term, like pelvic infection or reproductive tract infection, Dr. Cigna said. That would also include urinary tract infections, pelvic inflammatory disorder and yeast infections, without tying these conditions solely to sex.
Dr. Gordon describes bacterial vaginosis as “bacteria that naturally occurs in the vagina and just got out of hand,” she said. “I would think of it more like: you over-fertilized your lawn.”
“Oh, I like that,” said Dr. Cigna, of Dr. Gordon’s framing. “I might steal that.”
Rachel E. Gross is the author of “Vagina Obscura: An Anatomical Voyage.”
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